medicare parts a & b appeals process2 medicare parts a & b appeals process. appointing a...
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DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid Services
Medicare Parts A & B Appeals Process
ICN 006562 February 2015
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Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare).
Medicare Parts A & B Appeals Process
Table of Contents
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Overview 1
Appealing Medicare Decisions 1
Appointing a Representative 2
First Level of Appeal: Redetermination 3
Second Level of Appeal: Reconsideration 4
Third Level of Appeal: ALJ Hearing 5
Fourth Level of Appeal: Medicare Appeals Council Review 7
Fifth Level of Appeal: Judicial Review in U.S. District Court 8
Tips for Filing an Appeal 8
Appeal Process Summary 9
Resources 10
List of Tables
Table 1. Redetermination 3
Table 2. Reconsideration 4
Table 3. ALJ Hearing 5
Table 4. Medicare Appeals Council Review 7
Table 5. Judicial Review in U.S. District Court 8
Table 6. Appeal Process Summary 9
Table 7. Resources 10
1 Medicare Parts A & B Appeals Process
Overview
This fact sheet provides health care professionals with information about each level of appeal in Original Medicare (Parts A and B), as well as additional resources for information on related topics. It describes how the Medicare appeals process applies to providers and participating physicians and suppliers. In this fact sheet, the pronouns “I” or “you” refer to parties and appellants.
For more information on appeals, visit http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals on the Centers for Medicare & Medicaid Services (CMS) website, or scan the Quick Response (QR) code on the right with your mobile device. For information for beneficiaries about appeals, visit http://www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/original-medicare-appeals.html on the Medicare website.
Appealing Medicare Decisions
There are five levels in the claims appeal process under Original Medicare:
Level 1
Redetermination by a Medicare Administrative Contractor (MAC)
Level 2
Reconsideration by a Qualified Independent Contractor (QIC)
Level 3
Hearing before an Administrative Law Judge (ALJ)
Level 4
Review by the Medicare Appeals Council (Appeals Council)
Level 5
Judicial review in United States (U.S.) District Court
Make all appeal requests in writing.
Helpful TermsAmount in Controversy (AIC): The threshold dollar amount remaining in dispute that is required for a Level 3 and Level 5 appeal. The AIC increases annually by a percentage increase tied to a consumer price index.Appeal: The process used when a party (for example, a beneficiary, provider, or supplier) disagrees with an initial determination or a revised determination for health care items or services.Appellant: A person or entity filing an appeal.Determination: A decision made to pay in full, pay in part, or deny a claim.Escalation: When an appellant requests that an appeal pending at the QIC level or higher be moved to the next level because the adjudicator was not able to make a decision within a specified time.Non-Participating: Physicians and suppliers who choose to either accept or not accept Medicare assignment on a claim-by-claim basis. Non-participating physicians and suppliers have limited appeal rights.Party: A person or entity with standing to appeal an initial determination or subsequent administrative appeal decision.
2 Medicare Parts A & B Appeals Process
Appointing a Representative
At any time, a party may appoint any individual, including an attorney, to represent him or her during the processing of a claim or appeal. The representative helps the party by providing assistance and expertise.
To appoint a representative, the party or representative must complete Form CMS-1696 (at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207.html on the CMS website) or another written document with the same information. The form or other document must:
• Be in writing;
• Be signed and dated by the party and the representative (the representative’s signature must be dated within 30 days of the party’s signature);
• Include a statement appointing the representative to act for the party;
• Include a written explanation of the purpose and scope of the representation;
• Include the names, phone numbers, and addresses of both the party and the representative;
• Include the representative’s professional status or relationship to the party; and
• Contain a unique identifier of the represented party:If the party is the beneficiary, the Medicare number must be included. If the party is a provider or supplier, the National Provider Identifier (NPI) number is requested.
The appointment is valid for 1 year. During this year, the representative may represent the party in subsequent appeal levels on the initial appeal and for any appeals of other claims, unless the party specifically withdraws the representative’s authority.
Requirements for Appointment of RepresentativesFor more information, refer to the “Medicare Claims Processing Manual,” Chapter 29, Section 270, at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf on the CMS website.
Transfer of Appeal Rights to Non-Participating Physicians and Suppliers
Beneficiaries may transfer their appeal rights to non-participating physicians or suppliers who provide the items or services and do not otherwise have appeal rights. To transfer the appeal rights, the beneficiary and non-participating physician or supplier must complete and sign Form CMS-20031. To obtain this form, refer to http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20031.pdf on the CMS website.
3 Medicare Parts A & B Appeals Process
First Level of Appeal: Redetermination
A redetermination is the first level of appeal after the initial determination on a claim. It is a second look at the claim. Table 1 provides questions and answers about redeterminations.
In 2013, 5.6 percent of Part A claims and 2.9 percent of Part B claims resulted in redetermination requests.
Table 1. Redetermination
Question Answer
When must I file a request?
You must file a request for redetermination within 120 days from the date of receipt of the Remittance Advice (RA) that lists the initial determination.
How do I file a request?
File your request in writing by following instructions provided in the RA. Your request must be sent to the address listed on the RA (or follow instructions from your MAC on filing electronically). You may also file a request for redetermination by completing Form CMS-20027.
For the requirements for a written request or to access Form CMS-20027, visit http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/RedeterminationbyaMedicareContractor.html on the CMS website.
REMEMBER
• You, or your representative, must include your name and signature.
• Attach any supporting documentation to your redetermination request.
Is there a minimum AIC requirement?
No.
Who makes the decision?
MAC staff unassociated with the initial claim determination perform the redetermination.
How long does it take to make a decision?
MACs generally issue a decision within 60 days of receipt of the request for redetermination.
You will receive notice of the decision via a Medicare Redetermination Notice (MRN) from your MAC or, if the initial decision is reversed and the claim is paid in full, you will receive a revised RA.
NOTE: Certain Medicare rules enable you to correct minor errors and omissions on claims without initiating the appeals process. For more information, refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE0420.pdf on the CMS website.
4 Medicare Parts A & B Appeals Process
Second Level of Appeal: Reconsideration
If you disagree with the MAC redetermination decision, you may request a reconsideration by a QIC. A reconsideration is a review of the redetermination decision. Table 2 provides questions and answers about reconsiderations.
Table 2. Reconsideration
Question Answer
When must I file a request?
You must file a request for reconsideration within 180 days of receipt of the MRN or RA.
How do I file a request?
File your request in writing by following instructions provided on the MRN or RA. You may also file a request for reconsideration by completing Form CMS-20033.
For the requirements for a written request or to access Form CMS-20033, visit http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ReconsiderationbyaQualifiedIndependentContractor.html on the CMS website.
REMEMBER
• Clearly explain why you disagree with the redetermination decision.
• You, or your representative, must include your name and signature.
• You should submit:A copy of the RA or MRN;Any evidence noted in the redetermination as missing;Any other evidence relevant to the appeal; andAny other useful documentation.
Documentation submitted after you file the reconsideration request may extend the QIC’s decision timeframe.
NOTE: Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless you demonstrate good cause for submitting the evidence late.
Is there a minimum AIC requirement?
No.
Who makes the decision?
The QIC conducts the reconsideration, which is an independent review of the initial determination, including the redetermination and all issues related to payment of the claim. The reconsideration may include review of medical necessity issues by a panel of physicians or other health care professionals.
How long does it take to make a decision?
Generally, a QIC sends a decision to all parties within 60 days of receipt of the request for reconsideration. If the QIC cannot complete its decision in the applicable timeframe, it will inform you of your rights and the procedures to escalate the case to an ALJ.
NOTE: Before escalating your appeal to an ALJ, if you do not receive a decision on the reconsideration within 60 days, consider allowing an additional 5 to 10 days for mail delays.
5 Medicare Parts A & B Appeals Process
Third Level of Appeal: ALJ Hearing
If you disagree with the reconsideration decision or wish to escalate your appeal because the reconsideration period passed, you may request an ALJ hearing. The ALJ hearing gives you the opportunity, via video teleconference (VTC), telephone, or occasionally in person, to explain your position to an ALJ. The U.S. Department of Health & Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA), which is independent of CMS, is responsible for the Level 3 Medicare claims appeals. Table 3 provides questions and answers about ALJ hearings.
Table 3. ALJ Hearing
Question Answer
When must I file a request?
You must file a request for an ALJ hearing within 60 days of receipt of the reconsideration decision letter or after the expiration of the reconsideration period.
How do I file a request?
File your request in writing by following instructions provided in the reconsideration letter. You may also request an ALJ hearing by completing Form CMS-20034 A/B.
For the requirements for a written request, tips on filing an ALJ hearing request, or to access Form CMS-20034 A/B, visit http://www.hhs.gov/omha on the HHS website.
If you do not want a VTC or telephone hearing, you may ask for an in-person hearing, but you must demonstrate good cause. The ALJ determines whether the case warrants an in-person hearing on a case-by-case basis. You may also ask the ALJ to make a decision without a hearing (on-the-record).
REMEMBER
• You must send a copy of the ALJ hearing request to all other parties to the QIC reconsideration. If you are requesting the case be escalated to the Appeals Council, you must send a copy of the request to all other parties and to the ALJ.
• The ALJ sets hearing preparation procedures. CMS or its contractors may become a party to, or participate in, an ALJ hearing after providing notice to the ALJ and the parties to the hearing.
Is there a minimum AIC requirement?
Yes. You may only request an ALJ hearing if a certain dollar amount remains in controversy following the QIC’s decision. The AIC threshold is updated annually. For the current amount, visit http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/HearingsALJ.html on the CMS website.
To determine the AIC amount remaining in your appeal, visit http://www.hhs.gov/omha/faq/Requesting%20an%20ALJ%20Hearing/requesting_an_alj_hearing.html#HowistheAmountinControversy(AIC)calculated on the HHS website.
6 Medicare Parts A & B Appeals Process
Table 3. ALJ Hearing (cont.)
Question Answer
Who makes the decision?
The ALJ makes the decision. If the ALJ cannot complete its decision in the applicable timeframe, it will inform you of your rights and procedures to escalate the case to the Appeals Council.
The ALJ forwards the decision and case file to the Administrative QIC (AdQIC), which serves as the central manager for all ALJ Original Medicare claim case files. In certain situations, the AdQIC may refer the case to the Appeals Council on CMS’ behalf.
If no referral is made to the Appeals Council, and the ALJ decision overturns a previous denial (in whole or in part), the AdQIC notifies the MAC that it must pay the claim, according to the ALJ decision, within 30–60 days.
How long does it take to make a decision?
Due to an overwhelming number of new requests and the existing workload, OMHA has delayed new requests received after April 1, 2013, for ALJ hearing assignments.
OMHA remains committed to processing ALJ hearing requests in the order received and as quickly as possible, given pending requests and adjudicatory resources. OMHA prioritizes Part D prescription drug denial cases that qualify for expedited status and Medicare beneficiary issues. Additional delay can result from:
• Reconsideration-level escalations;
• The submission of additional evidence not included with the hearing request;
• The request for an in-person hearing;
• The appellant’s failure to send notice of the hearing request to other parties; and
• The CMS requested discovery.
If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council.
NOTE: Due to a record number of appeal requests, if 22 weeks have not lapsed since your initial ALJ hearing submission request, do not resubmit your request. For more information on these timeframes, visit http://www.hhs.gov/omha/important_notice_regarding_adjudication_timeframes.html on the HHS website.
NOTE: Due to the recent increase in the number of ALJ hearing requests, OMHA implemented two pilot programs, Settlement Conference Facilitation (SCF) and Statistical Sampling Initiative. SCF is an alternative dispute resolution process that uses mediation principles. Statistical Sampling Initiative applies to appellants with a large volume of claim disputes. For more information, visit http://www.hhs.gov/omha on the OMHA website.
7 Medicare Parts A & B Appeals Process
Fourth Level of Appeal: Medicare Appeals Council Review
If you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council review. The HHS Departmental Appeals Board (DAB) Medicare Operations Division administers the Appeals Council review. Table 4 provides questions and answers about Appeals Council reviews.
Table 4. Medicare Appeals Council Review
Question Answer
When must I file a request?
You must file your request for Medicare Appeals Council review within 60 days of receipt of the ALJ’s decision or after the ALJ ruling timeframe expires.
How do I file a request?
File your request in writing by following the instructions provided by the ALJ. You may also request an Appeals Council review by completing Form DAB-101.
For the requirements for a written request, tips on filing a request for Appeals Council review following an ALJ decision or dismissal, or to access Form DAB-101, visit http://www.hhs.gov/dab/divisions/medicareoperations on the HHS website.
REMEMBER
• Explain which part of the ALJ decision you disagree with and your reasons for the disagreement.
• You must send a copy of the Appeals Council review request to all the parties included in the ALJ’s decision.
Is there a minimum AIC requirement?
No.
Who makes the decision?
The Appeals Council makes the decision. If the Appeals Council cannot complete its decision in the applicable timeframe, it will inform you of your right and procedures to escalate the case to U.S. District Court.
The Appeals Council forwards the decision and case file to the AdQIC, which serves as the central manager for all Appeals Council Original Medicare claim case files.
If the Appeals Council decision overturns a previous denial (in whole or in part), the AdQIC notifies the MAC that it must pay the claim according to the Appeal Council’s decision within 30–60 days.
How long does it take to make a decision?
Generally, the Appeals Council issues a decision within 90 days from receipt of a request for review of an ALJ decision. If the Appeals Council review stems from an escalated appeal, then the Appeals Council has 180 days from the date of receipt of the request for escalation to issue a decision. A decision may take longer due to a variety of reasons.
If the Appeals Council does not issue a decision within the applicable timeframe, you may ask the Appeals Council to escalate the case to the judicial review level.
If you are requesting escalation to U.S. District Court, a copy of the request must be sent to all other parties and to the Appeals Council.
8 Medicare Parts A & B Appeals Process
Fifth Level of Appeal: Judicial Review in U.S. District Court
If you disagree with the Appeals Council decision, or you wish to escalate your appeal because the Appeals Council ruling timeframe passed, you may request judicial review. Table 5 provides questions and answers about judicial review in U.S. District Court.
Table 5. Judicial Review in U.S. District Court
Question Answer
When must I file a request?
You must file a request for judicial review within 60 days of receipt of the Appeals Council’s decision or after the Appeals Council ruling timeframe expires.
How do I file a request?
The Appeals Council’s decision (or notice of right to escalation) contains information on how to file a claim in U.S. District Court.
Is there a minimum AIC requirement?
Yes. You may only request judicial review if a certain dollar amount remains in controversy following the Medicare Appeals Council decision. The AIC threshold is updated annually. For the current amount, visit http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Review-Federal-District-Court.html on the CMS website.
Who makes the decision?
The U.S. District Court makes the decision.
Tips for Filing an Appeal
Now that we have discussed the five levels in the claims appeals process, here are some best practices when filing an appeal:
• Starting at Level 1, consolidate into one appeal as many similar claims as possible;
• File timely requests with the appropriate contractor;
• Include a copy of the decision letter(s) issued at the previous level;
• Include a copy of the demand letter(s) if appealing an overpayment determination;
• Include a copy of the Appointment of Representative (AOR) form if representing a provider/supplier/beneficiary;
• Respond promptly to the contractor requests for documentation; and
• Sign your request for appeal.
For information about the Medicare overpayment collection process, visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243389.html on the CMS website.
9 Medicare Parts A & B Appeals Process
Appeal Process Summary
A summary of each appeal level is provided in Table 6.
Table 6. Appeal Process Summary
Level Summary of review process
Who performs
the review?
When must you request an appeal?
When should you get a decision?
AIC
1st Level - Redetermination
Document review of initial claim determination
MAC Up to 120 days after you receive initial determination
60 days No
2nd Level - Reconsideration
Document review of redetermination (you should submit any evidence not previously presented at this level)
QIC Up to 180 days after you receive MRN/RA
60 days No
3rd Level - ALJ Hearing
May be an on-the- record review or an interactive hearing between parties
ALJ Up to 60 days after you receive notice of QIC decision or after expiration of the applicable QIC reconsideration timeframe if you do not receive a decision
May be delayed due to volume
Yes*
4th Level - Medicare Appeals Council Review
Document review of ALJ’s decision or dismissal (but you may request oral arguments)
Appeals Council
Up to 60 days after you receive notice of ALJ’s decision or after expiration of the applicable ALJ hearing timeframe if you do not receive a decision
90 days if appealing an ALJ decision
or
180 days if ALJ review time expired without an ALJ decision
No
5th Level - Judicial Review
Judicial review U.S. District Court
Up to 60 days after you receive notice of Appeals Council decision or after expiration of the applicable Appeals Council review timeframe if you do not receive a decision
No statutory time limit
Yes*
* The AIC threshold is updated annually. For the current amount, refer to the Related Links section at http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/HearingsALJ.html on the CMS website.
10 Medicare Parts A & B Appeals Process
Resources
For more information, refer to the resources in Table 7.
Table 7. Resources
Resource Website
Appeals Laws, Regulations, and Guidance
Social Security Act, Section 1869 http://www.ssa.gov/OP_Home/ssact/title18/1869.htm
42 Code of Federal Regulations (Part 405, Subpart I) http://www.gpo.gov/fdsys/pkg/CFR-2014-title42-vol2/pdf/CFR-2014-title42-vol2-part405-subpartI.pdf
“Medicare Claims Processing Manual,” Chapter 29 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf
Appeals Process by Medicare Part
http://www.hhs.gov/omha/process/Appeals%20Process%20by%20Medicare%20Type/appeals_process.html
MAC Contact Information http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map
Medicare Appeals Council http://www.hhs.gov/dab/divisions/medicareoperations
Medicare Learning Network® (MLN) Guided Pathways
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_Pathways_Basic_Booklet.pdf
The “Appeals” section in the “MLN Guided Pathways: Basic Medicare Resources for Health Care Professionals, Suppliers, and Providers” booklet provides more detailed information about Medicare appeals.
OMHA http://www.hhs.gov/omha
OMHA Medicare Appellant Forum
http://www.hhs.gov/omha/OMHA%20Medicare%20Appellant%20Forum
Original Medicare Appeals http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals
Part C Appeals http://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG
“Part C Appeals: Organization Determinations, Appeals & Grievances” Web-Based Training (WBT) Course
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html
11 Medicare Parts A & B Appeals Process
Table 7. Resources (cont.)
Resource Website
Part D Appeals http://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev
“Part D Coverage Determinations, Appeals & Grievances” WBT Course
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html
QICs http://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ReconsiderationbyaQualifiedIndependentContractor.html
Reopenings http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM4147.pdf
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE0420.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c34.pdf
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1426.pdf
U.S. District Courts http://www.uscourts.gov/FederalCourts/UnderstandingtheFederalCourts/DistrictCourts.aspx
12 Medicare Parts A & B Appeals Process
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